Provider Demographics
NPI:1134900830
Name:EVANS, STACEY R (LO)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:R
Last Name:EVANS
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8 ARBOR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-2576
Mailing Address - Country:US
Mailing Address - Phone:270-933-8084
Mailing Address - Fax:
Practice Address - Street 1:333 KENNEDY DR STE L202
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-7201
Practice Address - Country:US
Practice Address - Phone:860-482-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001826156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician